February 10th, 2013
What is your best treatment for “refractory” constipation?
In treating patients with constipation, we have several options for first-line agents: bulking agents/fiber, osmotic laxatives, or stimulant laxatives. When a patient has a suboptimal result, we commonly add or move to another class of laxative agents. Fortunately, most patients respond to these interventions, but we all have patients whose condition is “refractory” to these commonly used treatments. In the last few years, newer agents to manage constipation such as lubiprostone and linaclotide have also become available. But how best to manage these patients remains unclear, at least to me. So, here’s what I would like to know from you.
What do you use as first-line treatment in a patient with constipation?
What is your add-on treatment when your first-line treatment fails?
Do you use the newer agents, and if so, when? Do you use them to substitute for another agent or add them on?
In what circumstances do you consider surgery to treat constipation?
If a colonoscopy is negative, do you routinely use other diagnostic tests in a patient with constipation?
Looking forward to hearing your management strategies.
24 Responses to “What is your best treatment for “refractory” constipation?”
M. Brian Fennerty, MD
Editor-in-Chief
NEJM Journal Watch Gastroenterology
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I’ a pediatrician in Argentina. It’s common to check for chagasic megacolon here, and fortunately here in the South of the country we don’t find it.
First line: avoid dairy products (caseine)& increase fiber (both “as much as possible”).
Second line: lactulose
Rescue (exceptionally but not so infrequently): magnesium sulphate
Surgery: never
Colonoscopy: so infrequently that it approaches never.
Many of these patients have undiagnosed or undertreated hypothyroidism–of which constipation is a cardinal sign. The TSH level cannot be relied upon for diagnosis or treatment. Dysfunctional central hypothyroidism is more common than generally believed. So a symptomatic patient may have a normal TSH, but a free T4 that is low within the broad 95% population reference range. Patients treated with levothyroxine may have persisting hypothyroidism with TSH-normalizing therapy. Test for free T3 and look for signs/symptoms of hypothyroidism–fatigue, need for excessive sleep, cold extremities, dry skin, high cholesterol, etc. Sufficient treatment will require T4 and often T3 too in sufficient doses to raise both the FT4 and FT3 levels to higher points within the ranges. If the TSH is normal to begin with, it will be suppressed with sufficient treatment. TSH-suppressive therapy does not equal thyrotoxicosis if FT4 or FT3 are within the ref. range at 24hrs post dose and there are no symptoms or signs of thyrotoxicosis.
first of all: what is your definition of CONSTIPATION?.
thank you
dr. alfredo leiser
retaired gastroenterologist
israel
Add activity & exercise ~ 30 min/day.
Avoid/lower consumption of highly refined & processed foods.
Drink 1-2 10 oz. cups of warm water in am.
The first line treatment I use is increase vegetable intake, increase water intake, and increase exercise. The water alone often does it. If more intervention is needed, then I’ll add Magnesium before bed and/or ground flax or psyllium seeds (can sprinkle on yogurt or in salads/soups, or just taken plain….1 teaspoon for a few days with 8oz water and slowly work up to 1 tbsp/day. (If taken too much at first, can actually worsen constipation. And this much fiber must always be taken with 8 oz water.)
I’m surprised none of these ideas are mentioned or asked about above. The real problem is never an RX deficiency. The colon is meant to have fiber, water, and movement in order to work as intended.
I recall a 65 year old female patient who was presented at our G.I. rounds as an example of “refractory” constipation. She was scheduled for surgery that same day to remove redundant colon. She had the typical puffy face and “gravelly” voice of hypothyroidism and she reported that she felt weak and had slowed down over the previous year. It now took her twice as long to do her housework. Surgery was cancelled and lab tests confirmed the diagnosis of hypothyroidism which was successfully treated with thyroid harmone replacement. Following treatment all of her symptoms disappeared and she was able to live a normal life.
It is wise to screen all patients who present with severe constipation for hypothyroidism.
I am a 86 y/o retired phsician. I am presently taking moderate doeses of oxycodone for peripheral neuropathy secondary to spinal stenosis and disk disease for the last 12 years. After trying many different laxatives of many different classes the following works for me. I titrated docusate until I am taking 250mgs. tid after each meal. I am comfortable with tha dosage and I have few or no side effects such as diarrhea, pain, straining, hematachezia. Has anyone had similiar experience, positive or negative? I should like to know”
When I was undergoing clinical trial, the Revamid combination regimen caused a dramatic gastrostasis refractory to ordinary remedies. My GI specialist prescribed Domperidone which I obtained from Canada. Not marketed in US, but a generic widely used all over the world. It was effective and well tolerated.
I request routin lab test such : TSH,Ca, stool test,..
then colon transit time .if normal the socond line of treatment would be SSRI, col colchicin
Prunes, fruits, vegetables, magnesium oxide 400 daily, surfak, bran fiber, and formerly (when it was cheap) colchicine 0.6 mg. And fluids (water, tea, coffee)
Triphala 1 capsule TID.
Fybogel 1 sachet nocte
Fybogel 1 sachet nocte + Movicol 1-2 sachets mane
Fybogel 1 sachet nocte + Movicol 1-2 sachets t.d.s.
Have not used lubiprostone and linaclotide
Consider total colectomy if severely prolonged colonic transit study.
One lesson I learned with Pediatric GI long ago was to first do a “mini” bowel cleansing with Nulyte or MOM to give the patient 3-5 BMs before starting any new therapy, especially with moderate to severe constipation. With refractory, or severe constipation, I would use lubiprostone or linaclotide once daily, with or before a meal, respectively (typically supper in working woman to avoid the dilemma of stooling at work). This would be in addition to a PEG powder in the morning. With the advent of chloride channel activating agents, I have not resorted to surgery in years, though subtotal colectomy has been useful in women with ridiculously redundant bowels in the past.
milk of mag,miralax,add miralax,surgery-never,no.
i am eagerly awaiting the responses to these relevant questions from other experts in the field. However i would also like your own expert opinion, Dr Fennerty.
Dear Brian,
You have posted a great question that is difficult to answer because a certain number of patients with truly refractory constipation will have megacolons, enteric nerve cell damage and dropout in the colon and/or severe pelvic floor dysfunction. I frequently order a Sitzmark study to try to sort out the contributions of the problems to the patient’s case. I have had some success using lubiprostone 24 mgs bid, Miralax twice per day and one or two doses of liquid MOM per day. What we need is a true prokinetic agent that does not damage the enteric nervous system. I have started to use linaclotide 290mcgs. It is really potent and I have received many calls from IBS-C patients that are developing diarrhea on the reduced dose of 145 mcgs per day. I have had +/- results using linaclotide in patients with acquired megacolon.
In our hospital we use Gastrografin a idoine based contrast dye usually 100ml diluted with 100ml water in cases of refractory constipation borderling ileus especially in patients with high doses of opiods or peritoneal carcinosis.
Usually a very strong evacuation is achieved and then Laxoberal (Natriumpicosulphate) and Macrogrol do it´s work again.
A similar effect is usually achieved by the preparation for colonoscopy i.e. drinking 4l of Clean prep. etc. but it´s usually unnecessary execept it has never been done or other reasons for believing it could be cancer loom around.
I’m a pharmacist in Canada. I think at this point it’s time to break out the suppositories. I’d go with glycerin suppositories, or suppositories with laxative in them. Maybe use a suppository that has both.
First address diet, increase fibre and fluids and increase exercise
for younger patients trial fybogel bd , this is rarely effective for older population so in all those > 40 years I prescribe movicol 1 to 3 daily.. If ineffective add senna 2 alt days or sodium docusate 200mg alt nights.
For more resistant cases trial resilor 2mg increasing to 4mg whilst continuing movicol.
I tend to colonoscope older group ie > 50 years if constipation new symptom. I would like to do transit studies in all refractory cases but when not available do sweetcorn transit time!!
always check TFTs and Ca
For constipation refractory to all prescription medicine and noted above otc agents, I have had good luck with Alli ( the obesity medicine) and adding a tablespoon of olive oil with it as a chaser.